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JF%*,O,� <br /> Consent Fonn <br /> I have read the above information about hepatitis B and the synthetic <br /> B vaccine (REcoMBIVAX HB) . I have had an opportunityr tic hand- <br /> understand the benefits and risks of hepatitis vaccination.questions and <br /> - <br /> Understand understand that I must have three doses of vaccine to confer immunity. <br /> However, there is no guarantee that I will become immune or that I will not <br /> experience any adverse side effects from the vaccine. <br /> given to I request that it be <br /> me. <br /> Name of person to receive vaccine (print) <br /> 11�2r����j� f� <br /> Of pe �vii iec�lVing 'JdCi lilE <br /> kitnesds:�A& ate <br /> Date Vaccinated Lot No <br /> J� Q� Signature <br /> 1) —1 5 0 <br /> i <br /> , ,V e <br /> A2 - 9IR _n if <br /> AJ <br /> CS:er-8/15 <br />